Morton's neuroma is a painful thickening of the tissue surrounding an interdigital nerve in the forefoot — most commonly between the third and fourth metatarsal heads. Despite the name, it is not a true tumor but a perineural fibrosis caused by chronic nerve compression and irritation. It is one of the most common causes of forefoot pain and is significantly more prevalent in women, largely due to footwear habits.
Forefoot pain from Morton's neuroma can overlap with other conditions affecting the ball of the foot. A plantar plate tear and sesamoiditis can produce similar forefoot pain, and Freiberg disease of the metatarsal head is another important diagnosis to consider — particularly in younger female patients. MRI is the most reliable tool for distinguishing between these conditions.
Causes
- Footwear compression: High heels shift body weight onto the forefoot and compress the intermetatarsal spaces; tight, narrow toe boxes physically compress the metatarsal heads together, trapping the interdigital nerve. This is the primary reason women are affected far more often than men.
- Repetitive stress: Running, jumping, and sports with repetitive forefoot loading cause cumulative microtrauma to the interdigital nerve, triggering a fibrotic healing response around the nerve sheath.
- Foot structure: Flat feet, high arches, bunions, and hammertoes alter forefoot pressure distribution and increase mechanical stress on the interdigital nerves.
- Biomechanical abnormalities: Abnormal gait patterns, overpronation, and metatarsal length discrepancies concentrate load across specific intermetatarsal spaces.
- Prior trauma or nerve irritation: Past foot injuries or conditions causing chronic nerve irritation can initiate or accelerate perineural fibrosis.
Symptoms
- Burning or electric pain: A burning, sharp, or shooting pain in the ball of the foot, often radiating into the toes of the affected web space — most commonly the third and fourth toes.
- Numbness and tingling: Numbness, tingling, or a pins-and-needles sensation in the affected toes, caused by nerve compression.
- "Pebble in the shoe" sensation: Many patients describe the feeling of walking on a marble or a bunched-up sock under the ball of the foot — a hallmark symptom of Morton's neuroma.
- Swelling: Localized swelling at the affected intermetatarsal space may be present.
- Symptom pattern: Pain is consistently worsened by tight footwear and high heels, and relieved by removing shoes and massaging the forefoot. This pattern is highly characteristic and diagnostically useful.
Diagnosis
Physical examination includes direct palpation between the metatarsal heads to reproduce pain and the Mulder's click test — lateral compression of the forefoot while pressing on the intermetatarsal space produces a palpable or audible click with reproduction of symptoms. Numbness in the web space between the affected toes supports the diagnosis.
MRI is the gold standard imaging study for Morton's neuroma. It confirms the diagnosis, measures the size of the neuroma (a key factor in predicting response to treatment — neuromas under 5mm often respond to conservative care; those over 8mm more frequently require intervention), and rules out other causes of forefoot pain including plantar plate tears, intermetatarsal bursitis, stress fractures, and Freiberg disease. On MRI, Morton's neuroma appears as a teardrop-shaped soft tissue mass in the intermetatarsal space, most visible on coronal sequences. Ultrasound is a useful adjunct for real-time assessment and image-guided injection.
Treatments
Conservative treatment (effective for many patients, especially smaller neuromas):
Wide-toed footwear and avoidance of high heels are the essential first steps — without footwear modification, other treatments are unlikely to succeed. Metatarsal pads placed just proximal to the metatarsal heads splay the metatarsals and decompress the nerve. Custom orthotics address underlying biomechanical contributors. NSAIDs reduce pain and inflammation. Most patients with smaller neuromas improve significantly with these measures over 4–8 weeks.
Corticosteroid injections:
Ultrasound-guided corticosteroid injections into the affected intermetatarsal space are highly effective for short to medium-term relief and are a standard second-line treatment when footwear modification and orthotics are insufficient. A series of 2–3 injections spaced several weeks apart is typical. Response rates are good, though symptoms may recur over time.
Alcohol sclerosing injections:
A series of dilute alcohol injections (typically 4–7 sessions) progressively ablates the nerve fibers causing pain. Studies show good long-term outcomes with this approach, and it can effectively delay or avoid surgery. It is well tolerated and is a reasonable option for patients who have not responded fully to corticosteroid injections.
Extracorporeal Shockwave Therapy (ESWT):
A non-invasive option for neuromas that have not responded to injections. ESWT stimulates tissue remodeling and has shown benefit in reducing neuroma-related pain in several studies.
Surgical treatment (neurectomy):
When conservative measures fail after 3–6 months, surgical excision of the affected nerve segment (neurectomy) is indicated. The procedure is performed through a dorsal or plantar approach and reliably eliminates pain in the majority of patients. Patients should be counseled preoperatively that permanent numbness in the affected web space is the expected outcome — the nerve is removed, so sensory loss is an intended result, not a complication. Recurrence neuromas can develop at the proximal nerve stump and may require revision surgery.
Get an MRI to Confirm Your Diagnosis
Before surgical planning or starting treatment, a clear MRI diagnosis ensures the right path forward. First Look MRI offers self-pay Foot and Ankle MRI scans — no doctor's order or insurance required — at our locations in Georgia, Texas, and Colorado.